The Long Haul
Jul 20, 2017 · 3 min read

Stress Fractures in Female Endurance Athletes

Female participation in endurance racing events has been increasing since the passing of Title IX, which abolished discrimination based on sex, and afforded women equal opportunities in athletics. With this rise in female athletes, it is important to identify risk factors for injury in females. In particular, one overuse injury that is more prevalent in females then their male counterparts are stress fractures. A study conducted in 2011 out of Children’s Hospital Boston revealed that “Girls who engaged in 8 or more hours of activity per week were twice as likely as their peers to who engaged in less than four hours of activity to develop a stress fracture” (Field et al., 2011). Stress fractures occur over time as the bones see repeated stressors, often in the setting of low energy or hormone availability, and the bones fail to remodel after overload. Stress fractures commonly occur in the tibia, femur, and metatarsals.

Risk factors for stress fractures include: age, gender, training errors, menstruation, shoe wear, low bone density, and malalignment. The female anatomy can also predispose to injury with increased femoral internal rotation, valgus alignment at the knee, and increased foot pronation. The female athlete triad is a condition that consists of low energy availability, amenorrhea, and decreased mineral bone density, and is a risk factor that can lead to stress fractures and early onset osteoporosis.

Low energy availability occurs when there is improper nutritional intake. In endurance sports with high energy expenditure, there needs to be balanced intake. Energy intake can be compromised intentionally, inadvertently, or psychologically. If the female does not have access to proper nutritional intake, education on proper training techniques, or if there exists disordered eating or an eating disorder, this can affect the athlete’s nutritional status.

Amenorrhea, or lack of a menstrual period, can occur due to stress, or when the athlete’s weight drops below a healthy BMI. Primary amenorrhea is when a female does not menstruate prior to 15 years of age; whereas, secondary amenorrhea is when a female has menstruated in the past, but menses has since stopped. The athlete can have hormone altercations in a part of the brain called the hypothalamus, and the secretion of estrogen which is vital to the bone formation can be disrupted (Nazem & Ackerman, 2012).

High impact athletes with irregular menstrual cycles and inadequate nutritional intake are susceptible to decreased bone mineral density. Females have the highest rate of bone growth in the teenage years from 11–14 years (Nazem & Ackerman, 2012). When bone growth is interrupted due to limited availibility of nutrients or hormones, early onset of osteoporosis and stress fractures can occur.

Treatments of stress fractures vary based on the location of the fracture, but all require a period of rest and activity restriction. Often, plain radiographs or an MRI are required, and the physician may recommend a period of time with no weight bearing or wearing a brace. A bone stimulator can be prescribed to aid the bones in healing, depending on patient age and fracture location. NSAIDs can delay bone healing and should be avoided. In some cases, surgery may be necessary to stabilize the fracture site.

During recovery, the goal of the treating physician is to treat the injury itself, but also address any predisposing factors that may make the athlete susceptible. Pre-participation screening can have a role in preventing injury. There should be a conversation about nutrition with the medical provider. When a female athlete is no longer menstruating, ovulation can become affected, and an athlete should speak to a physician prior to resuming athletic activity. When the female is cleared for return to activity, the athlete should follow a program where they gradually increase mileage/yardage. Too much, too soon can lead to reinjury. Always seek a medical provider’s attention if you believe you have a stress fracture or a component of the female athlete triad.

References

Field, Alison E., Catherine M. Gordon, Laura M. Pierce, Arun Ramappa, and Mininder S. Kocher. “Prospective Study of Physical Activity and Risk of Developing a Stress Fracture among Preadolescent and Adolescent Females.” Archives of Pediatrics & Adolescent Medicine. U.S. National Library of Medicine, Aug. 2011.

Nazem, T. G., & Ackerman, K. E. (2012). The Female Athlete Triad. Sports Health, 4(4), 302–311.

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The Long Haul

Written by

Fiona Nugent, Sports Medicine Nurse Practitioner | Columbia University Sports Medicine | Endurance running injury prevention, diagnosis, management

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